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Original Investigation |

A 2-Hour Diagnostic Protocol for Possible Cardiac Chest Pain in the Emergency Department:  A Randomized Clinical Trial

Martin Than, MBBS1; Sally Aldous, MD1; Sarah Jane Lord, MBBS2; Stephen Goodacre, PhD3; Christopher M. A. Frampton, PhD4; Richard Troughton, PhD4; Peter George, MBBS1; Christopher Michael Florkowski, MD5; Michael Ardagh, PhD4; David Smyth, MD1; David Lewis Jardine, MD1; William Frank Peacock, MD6; Joanna Young, PhD1; Gregory Hamilton, PhD7; Joanne M. Deely, PhD7; Louise Cullen, MBBS8; A. Mark Richards, MD4
[+] Author Affiliations
1Emergency Department, Christchurch Hospital, Christchurch, New Zealand
2University of Sydney, Sydney, Australia
3University of Sheffield and Northern General Hospital, Sheffield, England
4University of Otago, Christchurch, New Zealand
5Canterbury Health Laboratories, Christchurch, New Zealand
6Baylor College of Medicine, Houston, Texas
7Canterbury District Health Board, Christchurch, New Zealand
8Royal Brisbane and Women’s Hospital, Herston, and Queensland University of Technology, Brisbane, Australia
JAMA Intern Med. 2014;174(1):51-58. doi:10.1001/jamainternmed.2013.11362.
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Importance  Patients with chest pain represent a high health care burden, but it may be possible to identify a patient group with a low short-term risk of adverse cardiac events who are suitable for early discharge.

Objective  To compare the effectiveness of a rapid diagnostic pathway with a standard-care diagnostic pathway for the assessment of patients with possible cardiac chest pain in a usual clinical practice setting.

Design, Setting, and Participants  A single-center, randomized parallel-group trial with blinded outcome assessments was conducted in an academic general and tertiary hospital. Participants included adults with acute chest pain consistent with acute coronary syndrome for whom the attending physician planned further observation and troponin testing. Patient recruitment occurred from October 11, 2010, to July 4, 2012, with a 30-day follow-up.

Interventions  An experimental pathway using an accelerated diagnostic protocol (Thrombolysis in Myocardial Infarction score, 0; electrocardiography; and 0- and 2-hour troponin tests) or a standard-care pathway (troponin test on arrival at hospital, prolonged observation, and a second troponin test 6-12 hours after onset of pain) serving as the control.

Main Outcomes and Measures  Discharge from the hospital within 6 hours without a major adverse cardiac event occurring within 30 days.

Results  Fifty-two of 270 patients in the experimental group were successfully discharged within 6 hours compared with 30 of 272 patients in the control group (19.3% vs 11.0%; odds ratio, 1.92; 95% CI, 1.18-3.13; P = .008). It required 20 hours to discharge the same proportion of patients from the control group as achieved in the experimental group within 6 hours. In the experimental group, 35 additional patients (12.9%) were classified as low risk but admitted to an inpatient ward for cardiac investigation. None of the 35 patients received a diagnosis of acute coronary syndrome after inpatient evaluation.

Conclusions and Relevance  Using the accelerated diagnostic protocol in the experimental pathway almost doubled the proportion of patients with chest pain discharged early. Clinicians could discharge approximately 1 of 5 patients with chest pain to outpatient follow-up monitoring in less than 6 hours. This diagnostic strategy could be easily replicated in other centers because no extra resources are required.

Trial Registration  anzctr.org.au Identifier: ACTRN12610000766011

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Figure 1.
Trial Profile

Accelerated diagnostic protocol (ADP) included Thrombolysis in Myocardial Infarction (TIMI) score for unstable angina and non-ST elevation acute coronary syndrome of 0, electrocardiogram, and 0- and 2-hour troponin testing.25aThree patients assigned to the control pathway received treatment via the experimental pathway and were discharged early. bForty-one patients assigned to the experimental pathway and classified as low-risk received standard care. These patients were admitted for further inpatient investigation for acute coronary syndrome (n = 35) or because an alternative diagnosis requiring admission had become apparent (n = 6). None of these patients had an acute coronary syndrome. No study patients were lost to follow-up or excluded from the analysis.

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Figure 2.
Hospitalization Times for Patients Randomized to Each Diagnostic Pathway

ADP indicates accelerated diagnostic protocol.

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